Many experts agree that at 18% of gross domestic product, health care (to paraphrase Shakespeare) is eating the country out of house and home.
“The average cost of treating the most common cancers has increased, and as more expensive targeted therapies and other new technologies become the standard, things will escalate more rapidly. But despite high expenditures, disparities in outcomes persist,” said Patricia A. Ganz, MD, Professor, UCLA Jonsson Comprehensive Cancer Center, Los Angeles, and Co-Chair of the National Cancer Policy Forum Workshop Planning Committee, as she opened the recent meeting on Delivering Affordable Cancer Care in the 21st Century at the Institute of Medicine (IOM) in Washington, DC.
Critical Considerations
IOM President Harvey V. Fineberg, MD, PhD, went on to say that three critical points have to be part of cost-containment considerations:
First, Quality of care must be maintained. Second, the kinds of costs involved must be examined, including personal out-of-pocket expenses, insurance reimbursement, the public purse, and other types of payment. He noted that cancer care is a major cause of personal bankruptcy and that shifting costs from one pocket to another doesn’t necessarily lower them.
Finally, policymakers must be willing to look at many strategies at once: cheaper drugs, efficiency of care delivery, prevention, research. “We must be prepared to use every tool in the toolbox, and it is ethically imperative that we involve patients in the endeavor.”
Challenges Are Many and Diverse
Scott Ramsey, MD, PhD, Director of Research and Economic Assessment in Cancer and Healthcare, Fred Hutchinson Cancer Research Center, Seattle, said that the United States spends at least twice as much on health care as other developed countries, but life expectancy and other critical measures lag behind many of them.
He noted that the population is growing and aging; obesity and other risk factors increase the likelihood of cancer; and the public doesn’t understand treatment and consequently makes unrealistic demands. Moreover, there is poor reimbursement for cognitive care (but it is better for chemotherapy and procedures); providers are stressed and burning out; and the value of care is significantly affected by the presence and type of insurance.
Mark B. McClellan, MD, Senior Fellow, The Brookings Institution, Washington, DC, added that there is a misalignment between what matters most to patients (availability of 24-hour response from physician offices and phone consultation, for instance) and what is reimbursed.
He listed key elements of real reform:
- Data measurement and evidence of benefit and harm
- Changes in the way benefits are paid to providers in the accountable care system and performance-based payment for drug reimbursement
- Patients’ ability to make real choices in health insurance plans
“The era of providing high-cost interventions with little benefit must end. A 600% increase in cancer care over the past 30 years—with inconsistent outcomes—is unsustainable,” said Jeffrey Peppercorn, MD, MPH, Associate Professor of Medicine, Duke University Medical Center, Durham, North Carolina.
Parameters of Value
Dr. Peppercorn addressed some of the factors that contribute to high costs for cancer care: high costs for development of new therapy, lack of clinical and economic studies to guide evidence-based care, lack of awareness or willingness to follow evidence-based practice when data is available, and lack of adequate sociopolitical debate on the real choices we face.
In addition, he noted that we need to recognize distinct aspects of this challenge. “We must differentiate between costs to society and costs to individual patients, and in the United States, the challenge of dealing with costs to patients is compounded by the fact that almost 50 million are currently uninsured and an additional 29 million are underinsured,” Dr. Peppercorn continued. “On a societal level, we must find the resources to provide interventions that have high value to everyone in need, while at the same time finding ways to reduce or eliminate practices that do no have proven benefit.”
But what are the parameters of value? And who defines value: the state, physicians, patients, insurers, a panel of experts?
Dr. Peppercorn enumerated several of the challenges we face in seeking to control costs and preserve or improve quality and access:
- How can they be most efficiently, ethically, and equitably allocated?
- To what extent do we view health care as a commodity?
- How do we curb overutilization?
- How do we balance cost control and clinical freedom and discretion?
- How do we incentivize best care?
- How and when should physicians consider the cost of care, and when should they discuss it with patients?
Patients Are Vulnerable
Veena Shankaran, MD, Assistant Professor of Medical Oncology, Fred Hutchinson Cancer Research Center, added that not only is the patient’s share of costs increasing, but insurance premiums have gone up significantly, sometimes by 100%. Deductibles, copayments, and out-of-pocket expenses for off-label diagnostics and treatments also are on the rise.
“Patients are financially vulnerable,” she said. “They are inundated with nonmedical costs, and often they’re too sick to work. Sometimes financial hardships lead to noncompliance, and sometimes patients are so scared that they accept any treatment at any price, regardless of potential benefit.”
More spending is not necessarily the answer. “We need better outcomes and better value,” Dr. Shankaran said. She thinks it is imperative for oncologists to discuss cost with patients and families (including convenience, distance from the cancer center, transportation expenses, and the like) and make it part of the treatment decision. Therefore, physicians need to know what various treatments cost, both reimbursed and out-of-pocket. It is true, she added, that these discussions are time-consuming (and mostly unreimbursed), and many physicians don’t know how to conduct them.
“But the bottom line is if there is no evidence of benefit, regardless of cost, we shouldn’t recommend it,” she concluded.
What the Problem Is and What It Isn’t
Ezekiel J. Emanuel, MD, PhD, Diane v.S. Levy and Robert M. Levy University Professor, Perelman School of Medicine, University of Pennsylvania, Philadelphia, threw out another giant number: $2.8 trillion spent on health care in 2012—the same as the entire gross domestic product of France.
“The United States is on a different planet [compared to other countries] when it comes to health-care spending,” said Dr. Emanuel. “And it is by no means benign.” It affects:
- Who can be covered by health insurance (Medicare and Medicaid will rise from 4.5% of the economy today to 20% by 2050.)
- State budgets and support of education, in some states escalating tuition at colleges and universities
- Middle-class wages. For instance, over the past 30 years, health insurance premiums have increased by 300% after inflation, corporate profits increased 200% after taxes, and net worker income in private industries declined by 4%.
- America’s long-term fiscal stability and status as a world power
He added that 50% of the population uses 3% of total health-care cost, while 10% uses 63%. “And the quality of care is equally uneven.”
Many ideas about cost control aren’t real, Dr. Emanuel commented. “Physicians often ignore their own role and fail to change the way they practice. They blame medical malpractice and defensive medicine costs, insurance company profits, drug costs, and demanding patients.”
These factors exist, he said, but for example, medical malpractice costs $35 billion, 2% of total cost. Defensive medicine comes in at $66 billion: 3% of the total. And yes, insurance companies are profitable ($11.7 billion in 2010), but he said this represents only a drop in the bucket. And there is no evidence that demanding patients are culprits. People who use more than $1 million in care use 0.5% of the total, and those who use $250,000 use 6.5% of the total.
Nevertheless, all these drops in the bucket and small percentages of the total add up to far more than small change.
Screening, Diagnosis, and Value
Otis W. Brawley, MD, Chief Medical Officer, American Cancer Society, said that some people consume too much (unnecessary) health care, and some do not receive what is necessary. But despite the negative connotation of the word, health care is indeed being rationed. “A substantial portion of people do not get adequate care—up to 30% of breast cancer patients and 20% of those with colon cancer, for instance.”
Many of the problems stem from screening issues, such as:
- A perception that all cancer is bad and must be found early and treated aggressively
- The belief that there is no such thing as overdiagnosis
- Thinking that increases in 5-year survival are evidence that screening is beneficial
- Confusion of relative risk and absolute risk
- Nonconformity with established screening and treatment guidelines, many of which are flawed to begin with
Dr. Brawley also listed areas of overuse: imaging, expensive drugs (brand name vs generic), and screening for lung, breast, cervical, and prostate cancers. This results from ignoring known science and the “greedy feeding the gluttonous.” He added, “We are tolerating a subtle form of corruption.”
True health-care reform will involve evidence-based care and prevention for everyone. “It is possible to decrease costs, improve outcomes, and reduce disparities by using science to guide our policies,” said Dr. Brawley. “However, a plan that would truly lower costs, maintain quality, and be fair to everyone would involve significant changes in the ways we currently do health-care business. ■”
Disclosures: Drs. Ganz, Fineberg, Ramsay, Peppercorn, Shankaran, McClellan, Emanuel, and Brawley reported no potential conflicts of interest.
